Confronting Racial Disparities in Prostate Cancer Survival Outcomes

Prostate cancer also appears to be more aggressive in African American men, transforming into advanced metastatic disease at a 4:1 ratio compared with white patients.

Those findings, a study of autopsy data from 1056 black and white men concluded, “support the concept that prostate cancer grows more rapidly in black than in white men and/or earlier transformation from latent to aggressive prostate cancer occurs in black than in white men.”⁴

Yet other factors may be at play.

Multiple studies found an association between socioeconomic status (SES) and worse prostate cancer outcomes. An analysis of California Cancer Registry data found, for example, that patients living in lower SES neighborhoods had a higher risk of death.⁵

This finding matches the results of a broader analysis of African American patients with breast, prostate, and colorectal cancer, which found that these patients are more likely to present with more advanced cancer, with the stage at diagnosis explaining 16% to 28% of survival disparities.⁶

A 2016 review of PubMed literature found that “African American men face several social barriers that [white] men may not, contributing further to their risk of poorer prognoses and outcomes.”⁷

The review cited a lack of health insurance, poor health–seeking behaviors that delay diagnosis, and “an inherent fear of a cancer diagnosis coupled with a mistrust of the health care system at large, [which] can significantly affect the outcome of African-American men with prostate cancer.”

Access to care is an issue across populations in a multitude of cancers, but a 2004 study published in The New England Journal of Medicine reported significant differences in the quality of care African Americans receive.⁸

“In a comparison of visits by white patients and black patients, we found that the physicians whom the black patients visited were less likely to be board certified (77.4 percent) than were the physicians visited by the white patients (86.1 percent)…and also more likely to report that they were unable to provide high-quality care to all their patients,” the authors reported.

These discrepancies result in dramatic differences in outcomes, as evidenced by the lower 5-year survival rates for African American patients with the same stage of cancer at the time of diagnosis as white men, according to a study of disparities by race and socioeconomic status.⁹

It’s an issue, Dr Etzioni said, that has implications for African American men throughout the entire range of treatment.

“In screening, for example,” she said, “are they getting biopsied as rigorously white men? In treatment we need to know: are they getting radiation at similar facilities that are able to give you the high quality of treatment, what they call hyperfractionated radiation?

“And for surgery — one thing that’s been shown for surgery is that it has to be done at a center where there’s a higher volume of patients. Are black men getting their surgery done at the large high-quality centers?”

Yet furthermore, even if all the treatment and care factors were equalized for African American and white patients, the former group would still face more dismal outcomes given their genetic predisposition for more and more aggressive cases of prostate cancer.

To fully eliminate racial disparities in prostate cancer mortality, Dr Etzioni said, physicians need to rethink what changes, philosophically and practically speaking, are required.

References

1. Kaur D, Ulloa-Pérez E, Gulati R, Etzioni R. Racial disparities in prostate cancer survival in a screened population: reality versus artifact. Cancer. 2018 Jan 25. doi: 10.1002/cncr.31253 [Epub ahead of print]
2. Haiman CA, Patterson N, Freedman ML, et al. Multiple regions within 8q24 independently affect risk for prostate cancer. Nat Genet. 2007;39(5):638-44.
3. Cancer health disparities. National Cancer Institute website. https://www.cancer.gov/about-nci/organization/crchd/cancer-health-disparities-fact-sheet. Updated March 11, 2008. Accessed March 2018.
4. Powell IJ, Bock CH, Ruterbusch JJ, Sakr W. Evidence supports a faster growth rate and/or earlier transformation to clinically significant prostate cancer in black than in white American men, and influences racial progression and mortality disparity. J Urol. 2010;183(5):1792-6. doi: 10.1016/j.juro.2010.01.015
5. DeRouen MC, Schupp CW, Koo J, et al. Impact of individual and neighborhood factors on disparities in prostate cancer survival. Cancer Epidemiol. 2018 Jan 9. doi: 10.1016/j.canep.2018.01.003 [Epub ahead of print]
6. Ellis L, Canchola AJ, Spiegel D, Ladabaum U, Haile R, and Gomez SL. Racial and ethnic disparities in cancer survival: the contribution of tumor, sociodemographic, institutional, and neighborhood characteristics. J Clin Oncol. 2018;36(1):25-33. doi: 10.1200/JCO.2017.74.2049
7. Shenoy D, Packianathan S, Chen AM, Vijayakumar S. Do African-American men need separate prostate cancer screening guidelines? BMC Urol. 2016;16(1):19. doi: 10.1186/s12894-016-0137-7
8. Bach PB, Pham HH, Schrag D, Tate RC, Hargraves JL. Primary care physicians who treat blacks and whites. N Engl J Med. 2004;351(6):575-84.
9. Ward E, Jemal A, Cokkinides V, et al. Cancer disparities by race/ethnicity and socioeconomic status. CA Cancer J Clin. 2004;54(2):78-93.